Medical Care Advisory Committee May 10, 2019 Responsibly providing access to quality health coverage for vulnerable Mississippians 1
State Plan Amendment (SPA) Updates SPA 18-0011 Physician Administered Drugs • Approved 2/14/19, Effective 7/1/18 SPA 18-0015 Disproportionate Share Hospital (DSH) Payments • CMS Submission 12/3/18 (Effective Date 10/1/18) • CMS RAI received 2/26/19 Children’s Health Insurance Program (CHIP) SPA #10 • CMS Submission 1/9/18 (Effective Date 1/1/18) • RAI Response 11/9/18
Proposed SPA Updates SPA 19-0001 Targeted Case Management for Beneficiaries with Intellectual and/or Developmental Disabilities in Community- Based Settings • CMS Submission 3/6/19 (Effective Date 1/1/19) SPA 19-0003 Non-emergency Transportation Broker Contract • CMS Submission 3/7/19 (Effective Date 2/1/19) SPA 19-0004 Prescription Drug Limit Increase • CMS Submission 5/3/2019 (Effective 7/1/2019) SPA 19-0006 Post-Eligibility Treatment of Income • CMS Submission 3/6/2019 (Effective 1/1/2019)
Proposed SPA Updates SPA 19-0009 Transitional Medical Assistance (TMA) • CMS Submission 3/7/2019 (Effective 1/1/2019) SPA 19-0010 Dental and Orthodontic Reimbursement • CMS Submission 3/28/2019 (Effective 3/1/2019) SPA 19-0015 Medicare Crossover Payments • Public Notice 4/23/2019 (Effective 7/1/2019)
Waiver Updates 1115 Workforce Training Initiative • Completeness Letter Received 1/22/18 • CMS Review in Process
Administrative Code Updates AC 19-004 Home Health Visit Increase (Effective 7/1/2019) • AC 19-005 Physician Visit Limit (Effective 6/1/2019) • • AC 19-007 FQHC PAD (Effective 6/1/2019) • AC 19-008 RHC PAD (Effective 6/1/2019) • AC 19-010 Timely Filing, Timely Processing of Claims (Effective 7/1/2019) • AC 19-016 PASRR Level 1 (Effective 6/1/2019) • AC 19-017 PASRR Part 303 to 206 (Effective 6/1/2019) • AC 19-020 CADD (Effective 6/1/2019) • AC 19-023 Incontinence Garments (Effective 7/1/2019) • AC 19-028 DME Home Evaluations (Effective 7/1/2019)
Old Business • Bariatric Surgery • Prosthetics • Reproductive Health LARC/ 17p • Pediatric Cardiac Care
New Business • Dental Sub-Committee • Long Term Care- Opportunities For Improvement • CCO- Pharmacy Best Practices and Management of High Utilizers – UnitedHealthcare Community Plan – Magnolia Health – Molina Healthcare
United Healthcare Pharmacy Best Practices 2018 – 2019 Retrospective Drug Utilization Review Programs 9
Retrospective DUR- Gaps in Care • 2018 Gap in Care program: Asthma Program • 2019: 5 programs - Asthma Program - COPD Program - Diabetes Program (2 parts) - Cardiovascular Program (6 parts) - HIV Program 10 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
2018/2019 Retrospective Drug Utilization Review Program- Asthma • Goal : To optimize the use of long-term controller medications and promote the appropriate use of short-acting beta-agonists • Member Inclusion: - Ages 5 through 85 years at start of identification period - Possess a medical and/or pharmacy claim representing asthma - Possess pharmacy claims indicating short-acting inhaler overutilization without the presence of a controller medication, OR - Possess pharmacy claims with a fill history indicating a low controller ratio ( 0 – 0.5) (filling their short acting inhaler much more frequently than the controller ) • Member Exclusion: - Possess a medical and/or pharmacy claim for emphysema, COPD, obstructive chronic bronchitis, chronic respiratory conditions due to fumes/vapors, cystic fibrosis, or acute respiratory failure - Members previously targeted for the same issue within the previous 180 days • Program : Daily provider fax/mail , with cover letter introducing the intervention and highlighting actions to be taken, with an accompanying report identifying patient(s) with potentially suboptimal asthma control who may benefit from a review of their asthma therapy and/or the addition of a controller • Outcomes: Clinical impact determined 120 days post prescriber outreach all YTD eligible RetroDUR Outcomes all YTD interventions eligible for interventions with a clinical impact % Summary outcomes LOB positive outcome Gaps In Care GIC Asthma MS CAN 1,833 285 15.55% MS CHIP 172 30 17.44% 11 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
New 2019 Retrospective Drug Utilization Review Program- COPD • Goal : To optimize the use of long-term controller medications and promote the appropriate use of short-acting beta-agonists in COPD • Member Inclusion: - Ages 40 and over at the start of the identification period - Possess a medical and/or pharmacy claim representing COPD - Pharmacy claims for • Member Exclusion: - Possess a medical and/or pharmacy claim for asthma, cystic fibrosis, or respiratory failure - Members previously targeted for the same issue within the previous 180 days • Program : Daily provider fax/mail , with cover letter introducing the intervention and highlighting actions to be taken, with an accompanying report identifying patient(s) with potentially suboptimal COPD control who may benefit from a review of their COPD therapy. Provider contacted is the most recent prescriber or one listed on any chronic medication. 12 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
2019 Retrospective Drug Utilization Review Program- Diabetes 1. Statin Use in Patients with Diabetes • Goal : To optimize the management of diabetes by identifying and closing the gap for members with diabetes not on a statin • Member Inclusion: - Ages 39-75 at the start of the identification period* - Possess a medical and/or pharmacy claim representing diabetes - Does not possess statin cla im within measurement period • Member Exclusion: - Possess a medical claim representing pregnancy, cirrhosis, lactation, muscular pain, ESRD - Possess a pharmacy claim for clomiphene Members previously targeted for the same issue within the previous 180 days • Program : Daily provider fax/mail , with cover letter introducing the intervention and highlighting actions to be taken, with an accompanying report identifying patient(s) with diabetes not on a statin. Provider contacted is the most recent prescriber of any diabetes medication. 13 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
2019 Retrospective Drug Utilization Review Program- Diabetes 2. Diabetes and Hypertension • Goal : To optimize the management of diabetes by identifying and closing the gap for members with diabetes and hypertension not on certain anti-hypertensive agent • Member Inclusion: - Ages 17 and up at the start of the identification period* - Possess a medical and/or pharmacy claim representing diabetes and hypertension - Does not possess a claim for Renin Angiotensin System Antagonist , thiazide diuretic , or calcium channel blocker within the measurement period • Member Exclusion: - Possess a medical claim representing pregnancy, ESRD - Possess a pharmacy claim for clomiphene - Members previously targeted for the same issue within the previous 180 days • Program : Daily provider fax/mail, with cover letter introducing the intervention and highlighting actions to be taken, with an accompanying report identifying patient(s) with diabetes and hypertension not on a certain antihypertensive agent. Provider targeted is the most recent prescriber of any diabetes medication. 14 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
2019 Retrospective Drug Utilization Review Program- Cardiovascular 1. Anti-Thrombin use in Atrial Fibrillation • Goal : To optimize the management of Afib by identifying and closing the gap for members in medication therapy for members with Afib not on an anti-thrombin agent. • Member Inclusion: - Ages 18 and up at the start of the identification period - Possess a medical claim representing atrial fibrillation - Does not possess a claim for anti-thrombin agent within the measurement period - Member Exclusion: - Possess a medical claim for a bleeding disorder - Members previously targeted for the same issue within the previous 180 days • Program : Daily provider fax/mail, with cover letter introducing the intervention and highlighting actions to be taken, with an accompanying report identifying patient(s) with afib and not on an anti-thrombin agent. Provider targeted is the most recent prescriber of any cardiovascular medication. 15 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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